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Medicaid Managed Care Initiatives December 2011. 2 STAR Capitated, Health Maintenance Organization (HMO) model for non-disabled pregnant women and children.

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Presentation on theme: "Medicaid Managed Care Initiatives December 2011. 2 STAR Capitated, Health Maintenance Organization (HMO) model for non-disabled pregnant women and children."— Presentation transcript:

1 Medicaid Managed Care Initiatives December 2011

2 2 STAR Capitated, Health Maintenance Organization (HMO) model for non-disabled pregnant women and children. Provides acute care services. STAR+PLUS Capitated HMO model for disabled Medicaid clients and dual eligibles (Medicaid and Medicare). Provides acute and long term services and supports (LTSS). Medicaid Service Delivery Models

3 3 STAR Health Capitated HMO model for foster care children. Provides acute care services with emphasis on behavioral health and medication management. Primary Care Case Management (PCCM) Non-capitated service delivery model. Includes non-disabled pregnant women, children and disabled adults. Acute care services only. Medicaid Service Delivery Models

4 Page 4 Medicaid Managed Care Initiatives Expand STAR and STAR+PLUS to South Texas. Expand STAR+PLUS to El Paso and Lubbock service areas. Convert PCCM Areas to the STAR Program model. Include In-patient Hospital Services in STAR+PLUS. Include pharmacy benefits in managed care. Expand Dental Managed Care Model for children in Medicaid.

5 5 STAR+PLUS Managed Care Service Areas

6 6

7 Page 7 Geographic Distribution of Managed Care Delivery Models

8 HMO Member Benefits Traditional Medicaid benefit package. Provider directories – physicians, specialists, and LTSS. PCP to coordinate health care of patient (Medicaid only). Member services helpline (through their health plan). Member handbooks and health education. Service Coordination. Value Added Services – vary by health plan.

9 Page 9 STAR Members Populations mandatory for STAR include: Temporary Assistance to Needy Families (TANF) recipients Pregnant Women Children receiving Medicaid assistance only Populations excluded from STAR include: Medicaid recipients who reside in institutions Medicaid recipients receiving Supplemental Social Security (SSI) Dual-eligible Medicaid recipients (clients with both Medicaid and Medicare) Medically needy Foster children Refugees Medicaid Rural Service Area: Children age 20 and younger can choose to join STAR if they receive SSI but do not receive Medicare.

10 10 STAR+PLUS Members STAR+PLUS Members Medicaid recipients who must participate in STAR+PLUS: SSI adults who are not: Residing in a Nursing Facility or other institution. Being served through a Home and Community Based Waiver program other than Community Based Alternatives (CBA). Non-SSI adults who qualify for 1915(c) Nursing Facility Waiver services must enroll in STAR+PLUS to receive those services. Medicaid recipients who can choose to participate in STAR+PLUS: SSI children, under age 21, may voluntarily enroll in STAR+PLUS. SSI children that do not volunteer will be in traditional Medicaid effective March 1, 2012.

11 Page 11 Managed Care vs. FFS FFS State operated plan. Providers are contracted directly with state. Providers paid fee-for-service (FFS) rates. Managed care Providers must contract and be credentialed with the health plan to provide services. Rates are negotiated between the provider and the MCO or DMO.

12 Page 12 PCCM vs. Managed Care Organizations Primary Care Case Management (PCCM) State operated plan. Providers are contracted directly with state. Members assigned PCP, but can see any Medicaid specialist. Providers paid fee-for-service (FFS) rates. Medicaid Managed Care Organizations Providers must contract and be credentialed with the MCO to provide STAR services. Rates are negotiated between the provider and the MCO.

13 Significant Traditional Providers Significant Traditional Provider (STP) requirements relate to providers that have been providing services to Medicaid clients in some service areas. MCOs are obligated to offer STP contractors the opportunity to be a part of the contracted MCO provider network. MCOs will reach out to contact STPs; however, STPs may initiate the contact. STP providers must accept MCO conditions for contracting and pass credentialing.

14 Public Health Coordination The MCO must make good faith effort to enter into a subcontract for covered services with public health entities. Services covered by public health entities may include: Sexually transmitted diseases Confidential HIV testing Immunizations Tuberculosis care

15 MCO Contract Requirements: Immunizations MCOs must educate providers on the following: Standard requirements in Chapter 161 of the Health and Safety Code ACIP Immunization Schedule AAP Periodicity schedule for CHIP members Texas Health Steps Periodicity schedule for Medicaid members. The screening provider is responsible for administration of immunizations and should not refer children to local health departments for immunizations. Compliance with ImmTrac requirements, including parental consent on the Vaccine Information Statement.

16 Page 16 Enrollment Broker Client Welcome letters/FAQs: Dental – September 2011 Medical – November 2011 Client Enrollment packets: Dental – November 2011 Medical – December 2011 through January 2012 Clients must enroll by February 10, 2012 or the state will assign a plan and main doctor.

17 Page 17 Enrollment Broker Enrollment Options Fill out the forms and mail them back. Call the Help Line and sign up by phone Attend a client outreach and enrollment event. Client outreach and enrollment events – November 2011 through February 2012

18 Page 18 Managed Care Operations HHSC Managed Care Operations monitors the HMO performance quarterly for these key indicators: Network Adequacy Claims Processing time Hotline Performance Complaint processing Additional contract requirements and performance is also monitored on ongoing basis.

19 Page 19 Provider Complaints Initial point of contact is MCO or dental plan May submit written complaint to HHSC at HHSC will intervene in issues when MCO is not complying with HHSC contract

20 20 Resources Resources HHSC Managed Care Proposals Webpage: TMHP Website:

21 Questions?


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